Provider Demographics
NPI:1700136868
Name:BAGNE, TARA E (DPT)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:E
Last Name:BAGNE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8077 155TH LN NW
Mailing Address - Street 2:
Mailing Address - City:RAMSEY
Mailing Address - State:MN
Mailing Address - Zip Code:55303-3888
Mailing Address - Country:US
Mailing Address - Phone:715-821-0684
Mailing Address - Fax:
Practice Address - Street 1:742 STERBENZ DR
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-8327
Practice Address - Country:US
Practice Address - Phone:715-386-2128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-17
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI55010159842251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics